Diagnosis, Investigations & Management
Based on: AHA/ACC/HFSA 2022 | ESC 2021 & 2023 Focused Update | JACC 2022 | HFAI 2025 Guidelines | ESC-HFA/HFAI Scientific Statement 2025
Key Trials: PARADIGM-HF • DAPA-HF • EMPEROR-Reduced • EMPEROR-Preserved • DELIVER • STEP-HFpEF • STRONG-HF
CLASSIFICATION OF HEART FAILURE
AHA/ACC/HFSA 2022 | ESC 2021 | HFAI 2025
HFrEF — Reduced EF: LVEF ≤ 40% HFmrEF — Mildly Reduced EF: LVEF 41–49% HFpEF — Preserved EF: LVEF ≥ 50% HFimpEF — Improved EF: Prior LVEF ≤40% → improved by ≥10% → now >40%
Global & Indian Epidemiology
| Parameter | Global | India (HFAI 2025) |
|---|---|---|
| HF Prevalence | ~64 million affected | 1.2/1000 (INDUS Study) |
| HFpEF proportion | ≥50% of all HF, rising | Hypertension major driver |
| HFrEF proportion | ~40–45% of HF cases | CAD prevalent in 52.5% of HFrEF |
| Key comorbidities | HTN, DM, AF, CKD | DM in 62.8% HFrEF; CKD in 13% |
| 5-year mortality | ~50% (all HF) | High but registry data limited |
Sources: AHA/ACC/HFSA 2022 (Heidenreich et al. Circulation 2022) | HFAI 2025 Guidelines | Trivandrum HF Registry | INDUS Study
ACC/AHA STAGES & NYHA FUNCTIONAL CLASSIFICATION
ACC/AHA Stages
Stage A — At Risk: Risk factors present (HTN, DM, obesity, family history of CM). No symptoms, no structural heart disease.
Stage B — Pre-HF: LV hypertrophy, reduced LVEF, prior MI, diastolic dysfunction. No prior or current HF symptoms.
Stage C — Symptomatic HF: Dyspnea, fatigue, exercise intolerance due to structural heart disease. Most patients in clinical practice.
Stage D — Advanced HF: Marked symptoms at rest despite GDMT. Requires specialized interventions (LVAD, transplant, palliative care).
NYHA Functional Class
Class I: No limitation of ordinary physical activity. Ordinary activity does not cause symptoms.
Class II: Slight limitation. Comfortable at rest; ordinary activity causes fatigue, dyspnea, or palpitations.
Class III: Marked limitation. Comfortable at rest; less-than-ordinary activity causes symptoms.
Class IV: Symptoms at rest. Any physical activity increases discomfort. Bed/chair-bound.
Source: AHA/ACC/HFSA 2022 Guideline. Circulation 2022;145:e895–e1032.
PATHOPHYSIOLOGY
HFrEF — Systolic Dysfunction
- Loss of functional cardiomyocytes (MI, ischaemia, toxins)
- Neurohormonal activation: ↑RAAS, ↑Sympathetic, ↑Aldosterone
- Maladaptive LV remodeling: dilatation, eccentric hypertrophy
- Reduced contractility → ↓stroke volume → ↓cardiac output
- Mitral regurgitation from annular dilatation compounds failure
- Progressive fibrosis, cardiomyocyte apoptosis
- Arrhythmia substrate → sudden cardiac death risk ↑↑
- Common causes: IHD, dilated CMP, LBBB, toxins, viral
HFpEF — Diastolic Dysfunction
- Normal/near-normal LVEF but impaired diastolic relaxation
- Concentric LV hypertrophy (pressure overload — HTN, AS)
- Increased LV wall stiffness → elevated filling pressures
- Impaired LV relaxation (abnormal lusitropy)
- LA dilatation → atrial fibrillation risk ↑
- Pulmonary venous HTN → dyspnea, exercise intolerance
- Systemic inflammation (obesity, DM) → myocardial fibrosis
- Common causes: HTN, obesity, DM, aging, HCM, infiltrative
Sources: ESC 2021 HF Guidelines | AHA/ACC/HFSA 2022 | Paulus & Tschöpe. JACC 2013;62:263–271
CLINICAL PRESENTATION
Symptoms
- Dyspnoea on exertion (cardinal symptom)
- Orthopnoea & paroxysmal nocturnal dyspnoea
- Ankle swelling / peripheral oedema
- Fatigue, exercise intolerance
- Nocturnal cough (may mimic asthma)
- Bendopnoea (SOB bending forward)
- Weight gain >2 kg/week (fluid retention)
- Reduced urine output
- Palpitations, pre-syncope
- Cardiac cachexia (advanced HF)
Signs
- Elevated JVP — hepatojugular reflux
- S3 gallop (LV volume overload — HFrEF)
- S4 gallop (stiff ventricle — HFpEF)
- Displaced apex beat (HFrEF)
- Mitral regurgitation murmur (functional)
- Bibasal crepitations (pulmonary oedema)
- Pleural effusions (dullness to percussion)
- Pitting oedema (ankles, sacrum)
- Ascites, hepatomegaly (right HF)
- Cheyne-Stokes respiration (advanced)
- Cold peripheries, low pulse pressure
HFpEF vs HFrEF — Clinical Clues
- HFpEF: often elderly, female, obese, hypertensive
- HFpEF: normal or near-normal heart size on CXR
- HFpEF: symptoms often exertional — exercise provocation needed
- HFrEF: dilated heart, S3 gallop, lower BP
- HFrEF: often younger males; post-MI, dilated CMP
- Both: can present with acute pulmonary oedema
- ESC 2021: Signs may be absent early in HFpEF
- HFpEF diagnosis often challenging — use scoring algorithms
- HFAI 2025: Rheumatic HD — consider in Indian patients
Sources: AHA/ACC/HFSA 2022 | ESC 2021 HF Guidelines | McDonagh TA et al. Eur Heart J. 2021;42:3599–3726 | HFAI 2025
INVESTIGATIONS — INITIAL WORKUP (Class I Recommendations)
BNP / NT-proBNP
- BNP <35 pg/mL or NT-proBNP <125 pg/mL: HF unlikely
- Acute setting: BNP <100 or NT-proBNP <300 excludes AHF (high sensitivity)
- Normal NP does NOT exclude HFpEF/HFmrEF — especially in obese patients
- Class I: Both ESC 2021 & AHA/ACC/HFSA 2022
12-lead ECG
- LBBB: predicts poor EF; triggers CRT evaluation
- LVH: suggests HFpEF, HTN, HCM, AS
- Q waves: prior MI / IHD-related HFrEF
- AF: major comorbidity; influences management
- Low voltage + thick walls: cardiac amyloidosis
- Prolonged QRS (≥150ms): CRT candidate (HFrEF)
Chest X-Ray
- Cardiomegaly (CTR >0.5): HFrEF
- Pulmonary venous congestion, Kerley B lines
- Bilateral pleural effusions
- Bat-wing hilar congestion (acute pulmonary oedema)
- Class I: Both ESC & AHA guidelines
- May be relatively normal in HFpEF
Blood Tests (Class I)
- CBC: anaemia, haematological causes
- Renal function (eGFR, creatinine): critical for GDMT
- Electrolytes (Na, K): safe GDMT initiation
- LFTs: hepatic congestion; drug monitoring
- TFTs: thyroid as reversible cause
- Fasting glucose / HbA1c: DM comorbidity
- Lipid profile: atherosclerotic risk assessment
Sources: ESC 2021 HF Guidelines (COR I for ECG, CXR, NPs, Bloods) | AHA/ACC/HFSA 2022 (COR I) | HFAI 2025
ECHOCARDIOGRAPHY — THE CORNERSTONE INVESTIGATION
Class I Recommendation — ESC 2021 | AHA/ACC/HFSA 2022
TTE: first-line imaging — classifies HF type, guides therapy
| Parameter | Normal Reference | Significance in HF |
|---|---|---|
| LVEF (Simpson’s biplane) | ≥55% | Defines HFrEF (≤40%), HFmrEF (41–49%), HFpEF (≥50%) |
| LV end-diastolic diameter | <5.5 cm | Dilated LV → HFrEF; normal size common in HFpEF |
| LV wall thickness | <1.0 cm (post. wall) | ↑ in HFpEF: LVH due to HTN, HCM, amyloid |
| E/e’ ratio (diastolic fn.) | <8 (normal) | E/e’ ≥15 = elevated LV filling pressures (HFpEF marker) |
| Deceleration time (DT) | 160–240 ms | DT <150ms = restrictive pattern — advanced HFrEF |
| LA volume index (LAVI) | <34 mL/m² | ↑ LAVI: chronic elevated LA pressure — HFpEF, AF |
| E/A ratio | 0.8–2.0 | <0.8 = impaired relaxation; >2.0 = restrictive pattern |
| RV systolic pressure (RVSP) | <35 mmHg | ↑ RVSP = pulmonary HTN — HFpEF, advanced HFrEF |
| TAPSE | >17 mm | Low TAPSE → RV dysfunction; adverse prognosis |
| GLS (Global Longitudinal Strain) | >−20% | Subclinical systolic dysfunction; reduced in HFpEF |
| IVC size & collapsibility | <2.1 cm; >50% collapse | ↑ IVC → elevated RA pressure; volume overload |
Sources: ESC 2021 (Table 5) | AHA/ACC/HFSA 2022 | Nagueh SF et al. JASE 2016;29:277–314
DIAGNOSING HFpEF — SCORING ALGORITHMS
HFA-PEFF Score (ESC-Endorsed)
| Domain | Criteria | Points |
|---|---|---|
| E — Echo (major) | E/e’ ≥15, TAPSE <17, LAVI ≥34 | 2 |
| E — Echo (minor) | E/e’ 9–14, LAVI 29–34, LVH, LVEF 40–49% | 1 |
| F1 — Functional | Exercise E/e’ ≥15 or PASP >55 mmHg | 3 |
| F1 — NT-proBNP | Sinus: >220 / AF: >660 pg/mL (rest) | 2 |
| F1 — NT-proBNP | Sinus: 125–220 / AF: 365–660 (rest) | 1 |
| Interpretation | ≥5 pts: HFpEF confirmed | 2–4: Indeterminate | 0–1: HFpEF excluded | — |
Indeterminate → Exercise stress echo or invasive haemodynamics (PCWP >15 mmHg)
ESC 2021 — Step-by-Step HFA-PEFF Algorithm
- Step 1 (P): Pre-test Assessment — Clinical features, ECG, NPs, basic echo
- Step 2 (E): Echo + NP Score — Major/minor criteria → score 0–5
- Step 3 (F1): Functional Testing — Diastolic stress echo / exercise haemodynamics
- Step 4 (F2): Final Aetiology — CMR, genetic testing, biopsy if needed
H2FPEF Score (AHA/ACC/JACC)
| Variable | Criteria | Points |
|---|---|---|
| H — Heavy (BMI) | BMI >30 kg/m² | 2 |
| H — Hypertension | ≥2 antihypertensives | 1 |
| F — Atrial Fibrillation | Paroxysmal or persistent AF | 3 |
| P — Pulmonary HTN | RVSP >35 mmHg on echo | 1 |
| E — Elder | Age >60 years | 1 |
| F — Filling pressure | E/e’ >9 on echo | 1 |
| Interpretation | 0–1: Low (1.6%) | 2–5: Intermediate | 6–9: High prob (>70%) | — |
Key Points — HFpEF Diagnosis:
- Normal NP levels do NOT exclude HFpEF (especially obese, HFmrEF)
- Provocative exercise echo: ↑ E/e’ >15 or PASP >55 = diagnostic
- Invasive PCWP >15 mmHg at rest (>25 mmHg on exercise) = definitive
- CMR: quantifies fibrosis, infiltration, morphology
- ESC 2021 + HFA-PEFF overlap: only 3.5% concordant HFpEF diagnosis
Sources: HFA-PEFF: Pieske et al. Eur Heart J 2019 | H2FPEF: Reddy et al. Circulation 2018 | ESC 2021 | AHA/ACC/HFSA 2022 | Scientific Reports 2025
HFrEF — FOUR PILLARS OF GDMT
AHA/ACC/HFSA 2022 & ESC 2021: All 4 Classes — Class I, COR A Evidence
Target: Initiate ALL 4 classes; up-titrate to maximally tolerated doses within 3–6 months
Pillar 1 — ARNi / RAS Inhibition
- Drugs: Sacubitril-Valsartan (preferred) | ACEi (Ramipril/Enalapril) | ARB (Candesartan/Losartan)
- Evidence: COR I, LOE A (ARNi) | PARADIGM-HF: 20% ↓ CV death/HFH | Superior to Enalapril
Pillar 2 — Evidence-Based β-Blockers
- Drugs: Carvedilol | Metoprolol succinate (CR/XL) | Bisoprolol
- Evidence: COR I, LOE A | MERIT-HF, CIBIS-II, COPERNICUS | ↓Mortality ~34%
Pillar 3 — Mineralocorticoid Receptor Antagonist (MRA)
- Drugs: Spironolactone | Eplerenone (Monitor K+, eGFR)
- Evidence: COR I, LOE A | RALES: ↓30% mortality | EMPHASIS-HF: Eplerenone
Pillar 4 — SGLT2 Inhibitor
- Drugs: Dapagliflozin 10 mg OD | Empagliflozin 10 mg OD (Regardless of DM status)
- Evidence: COR I, LOE A | DAPA-HF: ↓26% primary endpoint | EMPEROR-Reduced confirmed
Note: If ARNi not tolerated → use ACEi (preferred) or ARB | If ACEi-intolerant (cough) → ARB | DO NOT combine ACEi + ARB | Do not initiate β-blocker in acute decompensation
Sources: AHA/ACC/HFSA 2022 | ESC 2021 | PARADIGM-HF (NEJM 2014) | DAPA-HF (NEJM 2019) | EMPEROR-Reduced (NEJM 2020) | EMPHASIS-HF (NEJM 2011) | HFAI 2025
HFrEF GDMT — TARGET DOSES & MONITORING
| Drug | Starting Dose | Target Dose | Key Monitoring |
|---|---|---|---|
| ARNi | |||
| Sacubitril-Valsartan | 24/26 mg BD (or 49/51 mg BD) | 97/103 mg BD | BP, renal function, K+; 36h washout from ACEi |
| ACEi / ARB | |||
| Enalapril | 2.5 mg BD | 10–20 mg BD | Cr, K+, BP; avoid in bilateral RAS, angioedema |
| Ramipril | 2.5 mg OD | 10 mg OD | Cr, K+, BP; ACEi of choice if ARNi unavailable |
| Candesartan | 4–8 mg OD | 32 mg OD | K+, Cr, BP; use if ACEi-intolerant (cough) |
| β-Blockers | |||
| Carvedilol | 3.125 mg BD | 25 mg BD (>85 kg: 50 mg BD) | HR, BP, bronchospasm; avoid in acute decompensation |
| Bisoprolol | 1.25 mg OD | 10 mg OD | HR, AV block; preferred in CKD |
| Metoprolol succinate | 12.5–25 mg OD | 200 mg OD | HR, BP; use only XL/CR formulation |
| MRA | |||
| Spironolactone | 25 mg OD (or alternate days) | 50 mg OD | K+ (avoid if >5.0), Cr (avoid if eGFR <30); gynaecomastia |
| Eplerenone | 25 mg OD | 50 mg OD | K+, Cr; fewer hormonal side effects |
| SGLT2 Inhibitors | |||
| Dapagliflozin | 10 mg OD | 10 mg OD (fixed) | eGFR (avoid if <20), genital infections, DKA risk |
| Empagliflozin | 10 mg OD | 10 mg OD (fixed) | eGFR (avoid if <20), volume depletion; hold peri-op |
Sources: AHA/ACC/HFSA 2022 — Table 7 | ESC 2021 HF Guidelines — Table 12 | JACC 2022: How to Initiate and Uptitrate GDMT
HFrEF — ADDITIONAL PHARMACOTHERAPY
Beyond the Four Pillars: Selected Patients
Diuretics: Symptomatic relief in congestion (COR I) — no mortality benefit
Ivabradine (If-channel inhibitor)
- COR IIa (AHA 2022) / Class IIa (ESC 2021)
- Indication: HFrEF: LVEF ≤35%, sinus rhythm, resting HR ≥70 bpm, despite max-tolerated BB (or BB contraindicated)
- Dose: 2.5–7.5 mg BD
- Trial: SHIFT: ↓18% CV death/HHF; no mortality benefit
Hydralazine + Isosorbide Dinitrate
- COR I — Self-identified Black patients with LVEF ≤40% (AHA 2022) | COR IIa — Those intolerant of ACEi/ARB/ARNi
- Indication: Persistently symptomatic Black patients on GDMT; ACEi/ARB/ARNi-intolerant patients
- Dose: Hyd 37.5 mg + ISDN 20 mg TDS (target: 75 mg + 40 mg TDS)
- Trial: A-HeFT: ↓43% mortality in Black patients
Vericiguat (soluble guanylate cyclase stimulator)
- COR IIb (AHA 2022) / COR IIb (ESC 2021)
- Indication: Worsening HFrEF (recent HF hospitalisation or IV diuretics); LVEF ≤45%, on background GDMT
- Dose: 2.5 → 10 mg OD (titrate every 2 weeks)
- Trial: VICTORIA: ↓10% CV death/HHF (NNT=24); most benefit post-hospitalisation
Digoxin
- COR IIb (AHA 2022) / Class IIb (ESC 2021)
- Indication: Symptomatic HFrEF in sinus rhythm on optimal GDMT; HFrEF with rapid ventricular rate in AF (rate control)
- Dose: 0.125–0.25 mg OD (serum level 0.5–0.9 ng/mL); ↓dose in elderly, CKD, low body weight
- Trial: DIG trial: ↓HHF, no mortality benefit; narrow therapeutic window
Sources: AHA/ACC/HFSA 2022 | ESC 2021 | SHIFT (Lancet 2010) | VICTORIA (NEJM 2020) | A-HeFT (NEJM 2004) | DIG (NEJM 1997)
SLIDE 12: HFrEF — DEVICE THERAPY
Prerequisite: ≥3 months of optimal GDMT before device assessment (except primary prevention ICD post-MI)
ICD — Implantable Cardioverter Defibrillator (COR I)
- LVEF ≤35% on optimal GDMT ≥3 months — NYHA Class II or III
- Ischaemic HF: >40 days post-MI (SCD-HeFT, MADIT II)
- Non-ischaemic cardiomyopathy (DANISH, SCD-HeFT)
- Life expectancy >1 year with good functional status
- Class I — AHA 2022 & ESC 2021
CRT — Cardiac Resynchronisation Therapy (COR I)
- LVEF ≤35% + LBBB morphology + QRS ≥150 ms (COR I, LOE A)
- LVEF ≤35% + LBBB + QRS 120–149 ms (COR I, LOE B)
- LVEF ≤35% + non-LBBB + QRS ≥150 ms (COR IIa)
- CRT-D preferred in eligible patients (ICD + resync)
- Improves LVEF, symptoms, exercise capacity and survival
LVAD — Left Ventricular Assist Device (COR IIa — Stage D HF)
- Advanced HFrEF (LVEF ≤25%) — Stage D, refractory to GDMT
- Bridge to transplantation (BTT) or destination therapy (DT)
- INTERMACS profile 2–5 — ambulatory on oral therapy
- MOMENTUM 3: HeartMate 3 — ↓adverse events vs axial pump
- Driveline infections, stroke, RV failure remain key concerns
Heart Transplantation — Gold Standard for Advanced HF
- End-stage HF refractory to all therapies including LVAD
- 5-year survival ~70–80% in selected patients
- Key contraindications: fixed PVR >5 WU, active infection, malignancy
- Donor shortage major limitation
- HFAI 2025: Limited transplant centres in India; LVAD utilisation low
Sources: AHA/ACC/HFSA 2022 | ESC 2021 | SCD-HeFT (NEJM 2005) | MADIT-II (NEJM 2002) | CARE-HF (NEJM 2005) | MOMENTUM 3 (NEJM 2019) | HFAI 2025
HFpEF — MANAGEMENT
Unlike HFrEF, no single therapy has demonstrated clear all-cause mortality reduction in HFpEF.
| Treatment | COR (AHA 2022) | COR (ESC 2021/23) | Key Evidence / Notes |
|---|---|---|---|
| SGLT2i (Dapagliflozin / Empagliflozin) | COR IIa | Class I (ESC 2023 Update) | EMPEROR-Preserved: ↓21% HFH+CV death; DELIVER: ↓18% primary endpoint; 2023 ESC Update: upgraded to Class I across all LVEF |
| Diuretics (Furosemide / Torsemide) | COR I — Symptoms | Class I — Symptoms | Symptom relief and decongestion — universal; No proven mortality benefit |
| BP Control (target <130/80) | COR I | Class I | HTN is the primary modifiable driver of HFpEF; All evidence-based antihypertensives acceptable |
| MRA (Spironolactone/Eplerenone) | COR IIb | Class IIb | TOPCAT: HHF ↓17% (Americas subgroup); KAMO-HFpEF (Finerenone): FINE-ARTS HF ongoing; Benefits greater in LVEF <57% |
| ARNi (Sacubitril-Valsartan) | COR IIb (LVEF <60%) | Class IIb | PARAGON-HF: Trend to benefit in women & LVEF closer to 50%; AHA 2022: may be reasonable if LVEF <60% |
| ARB (Candesartan) | COR IIb | Class IIb | CHARM-Preserved: modest HHF reduction; Not superior to ACEi; NPs not significantly ↓ |
| AF Rate/Rhythm Control | COR IIa | Class IIa | AF worsens HFpEF significantly — treat aggressively; Cardioversion, ablation, rate control |
| Nitrates / PDE-5 Inhibitors | COR III (No Benefit) | Not recommended | RELAX trial: Sildenafil — no benefit; Routine use should be avoided |
| GLP-1 RAs (Semaglutide) | Emerging | Emerging (post-ESC 2023) | STEP-HFpEF & STEP-HFpEF-DM: ↓weight, ↑QoL, ↑6MWD; Obese HFpEF (BMI ≥30) — significant symptom benefit |
Sources: AHA/ACC/HFSA 2022 | ESC 2021 + 2023 Focused Update | EMPEROR-Preserved (NEJM 2021) | DELIVER (NEJM 2022) | PARAGON-HF (NEJM 2019) | TOPCAT (NEJM 2014) | STEP-HFpEF (NEJM 2023) | HFAI 2025
MANAGING KEY COMORBIDITIES IN HF
Iron Deficiency
- Prevalence: >50% CHF, ~80% AHF (with or without anaemia)
- Definition: Ferritin <100 μg/L OR 100–300 μg/L with TSAT <20%
- IV Ferric Carboxymaltose: COR IIa (AHA) / Class IIa (ESC)
- FAIR-HF, CONFIRM-HF: ↑QoL, ↑exercise capacity, ↓HHF
- 500–1000 mg IV over 10–15 min; recheck iron 2–3 months
- Oral iron: NOT advised (IRONOUT-HF: no benefit in HFrEF)
Atrial Fibrillation
- Most common arrhythmia in HF; bidirectional relationship
- Rate control: Beta-blockers (HFrEF) / digoxin / diltiazem (HFpEF only)
- Rhythm control: Amiodarone (preferred for cardioversion in HFrEF)
- CASTLE-AF: AF ablation ↓ mortality+HHF in HFrEF (LVEF <35%)
- COR IIa for ablation in symptomatic AF with HFrEF
- Anticoagulation: DOACs preferred over warfarin (CHA₂DS₂-VASc ≥2M/≥3F)
Diabetes Mellitus (T2DM)
- DM in >60% Indian HF patients (HFAI 2025 registry)
- SGLT2i: first-choice — benefit in ALL HF regardless of DM status
- GLP-1 RA (Semaglutide): ↑QoL and symptoms in obese HFpEF
- Metformin: generally safe in compensated HF (avoid if eGFR <30)
- Thiazolidinediones: CONTRAINDICATED (fluid retention, ↑HHF)
- Saxagliptin (DPP4i): ↑HHF in SAVOR-TIMI — avoid in HF
Chronic Kidney Disease
- CKD in 13% HF patients; both conditions worsen each other
- SGLT2i: nephroprotective + HF benefit (EMPA-KIDNEY trial)
- MRA: use with caution if eGFR <30 (hyperkalaemia risk)
- ACEi/ARB: acceptable if eGFR ≥30; STOP if K+ >5.5 or Cr rises >30%
- Cardiorenal syndrome: careful diuretic titration essential
- Dialysis patients: RRT does NOT reverse HF outcomes
Sources: AHA/ACC/HFSA 2022 | ESC 2021 | HFAI 2025 | FAIR-HF (NEJM 2009) | CASTLE-AF (NEJM 2018) | EMPA-KIDNEY (NEJM 2023) | SAVOR-TIMI 53 (NEJM 2013)
ACUTE HEART FAILURE — INITIAL MANAGEMENT
Initial 60–120 minutes: CHAMP mnemonic — rapid stabilisation protocol
C — Catheterise: Consider early coronary angio if ACS-related AHF; Rule out ACS (troponin, ECG, haemodynamics)
H — High flow O₂: Target SpO₂ 94–98% (or 88–92% in COPD); NIV (CPAP/BiPAP) for cardiogenic pulmonary oedema
A — Anticoagulate: If AHF + AF or DVT/PE; DOAC or LMWH — check contraindications
M — Monitor & Morphine: Haemodynamic monitoring (A-line, CVC if needed); Morphine: caution — may ↑mortality (ESC 2021: Class IIb)
P — Pacing if indicated: Complete heart block, symptomatic bradycardia; Temporary pacing wire if haemodynamically compromised
Pharmacological Management of AHF
| Therapy | Dose | Indication | COR / Notes |
|---|---|---|---|
| IV Loop Diuretic (Furosemide) | 40–80 mg IV bolus (naive); 2.5× oral dose if on chronic therapy | Congestion — first-line in all AHF | Class I |
| IV Nitrates (GTN/ISDN) | GTN: 10–200 mcg/min; ISO: 1–10 mg/h IV | AHF with BP >110 mmHg (Vasodilatory phenotype) | Class IIa |
| Dobutamine | 2.5–20 mcg/kg/min | Low-output state / cardiogenic shock (Inotropic support) | Class IIb |
| Vasopressors (Norepinephrine) | 0.01–0.3 mcg/kg/min | Cardiogenic shock with hypotension (MAP <65) | Class IIb |
| SGLT2i (Early initiation) | Dapagliflozin 10 mg OD | Initiated before/at discharge (DICTATE-AHF: ↑natriuresis) | Emerging COR IIa |
| Spironolactone at discharge | 25–50 mg OD | All HFrEF at discharge | COR I (chronic HFrEF) |
Sources: ESC 2021 HF Guidelines (AHF Section 4) | AHA/ACC/HFSA 2022 | HFAI 2025 | DOSE Trial (NEJM 2011) | DICTATE-AHF | COACH Trial
HFAI 2025 — INDIA-SPECIFIC GUIDANCE
Epidemiology & Aetiology
- CAD in 52.5% HFrEF; HTN major driver of HFpEF in Indian patients
- Rheumatic heart disease still a significant cause in younger patients
- DM in 62.8% HFrEF and 56.6% HFmrEF patients
- Trivandrum HF Registry: India’s largest HF registry (THFR 2013)
- INDUS Study: prevalence 1.2 per 1000 in urban/rural populations
HFpEF Classification (HFAI 2025)
- HFrEF: LVEF ≤40% | HFmrEF: 41–49% | HFpEF: ≥50%
- HFimpEF: Baseline LVEF ≤40% → improved by ≥10% → now >40%
- HFpEF treatment: Diuretics + SGLT2i + ARNi (if LVEF <57%)
- Finerenone (nonsteroidal MRA): awaited — FINE-ARTS HF trial
- HFimpEF: Continue GDMT; TRED-HF: 44% relapse if stopped
Iron Deficiency Management
- Iron deficiency in >50% CHF and ~80% AHF patients
- IV Ferric Carboxymaltose: 500–1000 mg in 50 mL saline over 10–15 min
- COR IIa: Improves QoL, exercise capacity, ↓HHF (FAIR-HF, CONFIRM-HF)
- Oral iron: NOT recommended — poor absorption in HF (IRONOUT-HF)
- Re-check plasma iron at 2–3 months; repeat if still deficient
Resource-Limited Setting Considerations
- HFA-ESC/HFAI Joint Statement 2025: SGLT2i across all LVEF spectrum
- Generic sacubitril-valsartan now available — improving affordability
- LVAD utilisation limited — fewer transplant centres in India
- Spironolactone preferred over eplerenone for cost-effectiveness
- Dapagliflozin and empagliflozin: both available as lower-cost generics
- Remote monitoring / telecardiology: recommended for follow-up
Source: HFAI 2025 Guidelines | HFA-ESC/HFAI Scientific Statement on SGLT2i, 2025 | Trivandrum HF Registry | INDUS Study
KEY TAKEAWAYS
Classification: HFrEF (≤40%) | HFmrEF (41–49%) | HFpEF (≥50%) | HFimpEF — each with distinct pathophysiology and therapeutic targets (AHA 2022, ESC 2021, HFAI 2025)
Diagnosis: Class I: NP (BNP/NT-proBNP), ECG, CXR, TTE for all. HFpEF diagnosis is challenging — use HFA-PEFF (ESC) or H2FPEF (AHA/JACC) scoring. Exercise haemodynamics or PCWP if indeterminate.
HFrEF GDMT — Four Pillars: ARNi (Sacubitril-Valsartan) + β-Blocker + MRA (Spironolactone/Eplerenone) + SGLT2i — ALL Class I, LOE A. Initiate all 4 and uptitrate within 3 months. Post-MI ICD if LVEF ≤35%.
HFpEF Treatment: SGLT2i is now Class I across all LVEF (ESC 2023 Update) — EMPEROR-Preserved & DELIVER. BP control (Class I). MRA (IIb), ARNi (IIb for LVEF <60%). Semaglutide in obese HFpEF. Nitrates: avoid (Class III: No Benefit).
Iron Deficiency: Screen all HF patients (ferritin + TSAT). IV Ferric Carboxymaltose (COR IIa) — improves QoL and reduces HHF. Oral iron: no benefit (HFAI 2025; IRONOUT-HF).
India-Specific (HFAI 2025): CAD + DM dominant in HFrEF; HTN drives HFpEF. Rheumatic HD persists. SGLT2i across full LVEF spectrum — endorsed by HFA-ESC/HFAI 2025. Cost-effective generics now available.
AHA/ACC/HFSA 2022 (Heidenreich et al.) • ESC 2021 & 2023 Focused Update (McDonagh et al.) • HFAI 2025 • HFA-ESC/HFAI Scientific Statement 2025